Atlas of Heart Anatomy and Development

254 Pages·2014·67.38 MB·English

by  Florin Mihail Filipoiu (auth.)

Florin Mihail Filipoiu
Atlas of Heart Anatomy
and Development
123
Atlas of Heart Anatomy and Development

Florin Mihail Filipoiu
Atlas of Heart Anatomy
and Development
Florin Mihail Filipoiu, PhD, MD
Anatomy Department
University of Medicine and Pharmacy
Carol Davila
Bucharest
Romania
Previously published in Romanian by Editura Prior & Books as Cordul: Anatomie, repere embriologice
si notiuni de infrastructura a miocardului - Atlas explicitat si comentat by Florin Mihail Filipoiu,
[2012], ISBN 978-6-0692-5063-1
ISBN 978-1-4471-5381-8 ISBN 978-1-4471-5382-5 (eBook)
DOI 10.1007/978-1-4471-5382-5
Springer London Heidelberg New York Dordrecht
Library of Congress Control Number: 2013951332
© Springer-Verlag London 2014
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction
on microfi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this
legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifi cally
for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work.
Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the
Publisher's location, in its current version, and permission for use must always be obtained from Springer. Permissions
for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution
under the respective Copyright Law.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not
imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
While the advice and information in this book are believed to be true and accurate at the date of publication, neither
the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may
be made. The publisher makes no warranty, express or implied, with respect to the material contained herein.
Printed on acid-free paper
Springer is part of Springer Science+Business Media (www.springer.com)
Pref ace
To write a book utilizing the extraordinary sources of information, which so many people have
access to, seems to have over-simplifi ed our fi eld. Perhaps, this is the way it should be.
However, it is my sincere belief that when one purchases a book, one must choose wisely as it
will infl uence their future. The method of how a book is written will infl uence your profes-
sional development.
Beyond the abundance of information lies the writer’s style, belief and respect for the sub-
ject and his peers. Basic information can be useful; however when combined with love, experi-
ence and “savoire faire”, it actually shapes the readers.
The development of this book took over 8 years. During this time, several times per week,
side-by-side with my assistants and a few enthusiastic students, we would spend hours in the
dissection laboratory. In the beginning, I did not wear glasses – however during this time, my
prescription doubled. My assistants went from being single to having children of their own
who now attend school. It took us over a year to realize what we did not know and subse-
quently rediscovered structure by structure.
I discovered the phenomenal history of how anatomical structures were initially described.
I read about anatomists who are no longer even mentioned; however their contribution to our
profession has been so powerful that they deserve to be recognized with statues. I have com-
pared opposite theories about the same structure and have supported those scientists that were
ignored by the contemporaries of their time. After a few years of this research, I was able to
develop a macro view. Ontogenesis and the cardiac anatomy were intertwined and supple-
mented admirably. After a while, we began to view information based on its clinical utility.
Subsequently, we commenced to form our own opinions which developed into theory.
I reached a profound moment when I was able to describe the myocardial architecture,
through the prism of biological utility and clinical function. It was like winning the World
Cup – only for me, it happened to be while I was alone, in front of my computer, late at night.
The hardest part was assembling my thoughts and ultimately my conclusions in a fi nal product.
The diffi culty of the editing process, however, was mitigated by virtue of the people that
I worked with. Along with my team-mates, I actually learned a new skill. I sincerely thank
them for their support and dedication. Towards the end, honestly, I even asked myself if all this
time and effort was worth it. I discovered that it was actually hard to be sincere with myself.
I immediately decided that I had to be sincere with you, my readers.
To write a book that has taken such a long time to put together and that required signifi cant
resources and energy is something that is very diffi cult to recommend embarking upon.
However, to experience the creation of intellectual capacity and the unparalleled feeling of
elation is something that is reserved for the souls of aristocrats. In the end, it is all a matter of
self-refl ection.
This book is dedicated to my children, Zoran and Serena, my niece Sabina and my parents.
A special thank you to my wife, Mirela, who has taught me the extraordinary lessons of will
power, ideals and priorities.
Bucharest, Romania Florin Mihail Filipoiu, PhD, MD
v

Contents
1 The General Development Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 The General Development Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1.1 The Germ Disk Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1.2 The Formation of the Endocardial Tubes . . . . . . . . . . . . . . . . . . . . . . . 1
1.1.3 The Primitive Heart Tube Formation . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1.4 The Formation of the Cardiac Prominence . . . . . . . . . . . . . . . . . . . . . 3
1.1.5 The Stage of Linear Cardiac Tube . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.1.6 The Cardiac Loop Stage
(The “U” Shaped Heart) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.1.7 The “Cor Sigmoideum” Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2 The Specifi c Development Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.1 The Formation and Septation of Atria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.1.1 The Formation of Septum Intermedium . . . . . . . . . . . . . . . . . . . . . . . 11
2.1.2 The Formation of Septum Primum . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.1.3 The Formation of Septum Secundum . . . . . . . . . . . . . . . . . . . . . . . . . 20
2.2 Interatrial Septal Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
2.3 Evolution of the Right Atrium and of the Sinus Venosus . . . . . . . . . . . . . . . . 27
2.3.1 Incorporation of the Right Horn of Sinus Venosus
in the Atrial Wall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
2.3.2 Sinusal Recesses and Their Evolution . . . . . . . . . . . . . . . . . . . . . . . . . 27
2.4 A New Approach Upon Formation and Biologic Utility of Todaro’s Tendon,
Regarding the Evolution of the Primitive Sinus Venosus Recesses . . . . . . . . . 29
2.4.1 Formation of Eustachian Margin and Evolution of Right Valve . . . . . 29
2.4.2 Formation of Todaro’s Tendon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
2.5 Evolutionary Signifi cance of the Sinusal Valves and Horns . . . . . . . . . . . . . . 31
2.6 Evolution of the Left Atrium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
2.7 Evolution of the Cardiac Bulb and Truncus Arteriosus
and Septation of the Primitive Ventricle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
2.7.1 Defi ning Bulbus Cordis and Its Components – the Trabecular
Part of the Right Ventricle, Arterial Conus and Trunk. . . . . . . . . . . . . 34
2.7.2 Spiral Septum Formation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
2.7.3 Separation of the Primitive Truncus Arteriosus into
the Aorta and the Pulmonary Trunk . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
2.7.4 Primitive Ventricle Septation and Interventricular Septal Defects . . . 39
2.7.5 Atrioventricular Septum Formation . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
2.8 The Differentiation of the Myocardium, of the Valvular Apparatus,
of the Vascularisation and the Extrinsic Nerve Supply of the Heart . . . . . . . . 42
2.8.1 Formation of the Working Myocardium . . . . . . . . . . . . . . . . . . . . . . . 42
2.8.2 Atrioventricular Valve Formation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
2.8.3 Tricuspid Valve Formation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
vii
viii Contents
2.8.4 Mitral Valve Formation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
2.8.5 Aortic Semilunar and Pulmonary Valve Formation . . . . . . . . . . . . . . . 48
2.8.6 Epicardium and Coronary Vessels Formation . . . . . . . . . . . . . . . . . . . 48
2.9 The Differentiation of the Fibrous Skeleton of the Heart
and of the Pacemaking and Conduction Tissue . . . . . . . . . . . . . . . . . . . . . . . . 51
2.9.1 Extracardial Cellular Contributions to the Consolidation
of the Pacemaking and Conduction System . . . . . . . . . . . . . . . . . . . . . 53
2.10 The Left-Right Axial Asymmetry Determinism
in the Heart Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
3 Concepts of Clinical Anatomy of the Heart: Defi nition,
Location and Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
3.1 Defi nition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
3.2 Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
3.3 Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
4 The External Confi guration of the Heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
4.1 The General Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
4.2 Views of the Sternocostal Surface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
4.3 Highlighting the Interatrial Notch and the Corona Cordis . . . . . . . . . . . . . . . . 76
4.4 Highlighting of the Pulmonary Face and the Identifi cation
Pattern of the Left Auricle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
4.5 Highlight of the Diaphragmatic Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
4.6 Highlight of the Right (Acute) Border of the Heart
and of the Identifi cation Pattern for the Right Auricle. . . . . . . . . . . . . . . . . . . 76
4.7 Highlight of the Radiological Contours
of the Heart on a Postero-anterior X-Ray . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
4.8 Highlight of the Base of the Heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
5 Boundaries of the Heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
5.1 The Border with the Sternocostal Surface . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
5.1.1 Highlighting the Internal Thoracic Arteries . . . . . . . . . . . . . . . . . . . . . 77
5.2 Pulmonary Surface Boundaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
5.3 Diaphragmatic Surface Boundaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
5.4 The Right Border Boundaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
5.5 The Boundaries of the Hearts Base . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
5.6 The Intrinsic Boundaries of the Pulmonary Pedicles . . . . . . . . . . . . . . . . . . . . 87
5.7 The Extrinsic Boundaries of the Pulmonary Pedicles . . . . . . . . . . . . . . . . . . . 88
6 Internal Confi guration of the Heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
6.1 Internal Confi guration of the Right Atrium . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
6.1.1 The Orifi ce of the Inferior Vena Cava, the Eustachian Valve,
Chiari’s Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
6.1.2 The Interatrial Septum: Right Surface, the Oval Fossa . . . . . . . . . . . . 96
6.1.3 The Dorso-Sinusal Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
6.1.4 The Tricuspid Vestibule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
6.1.5 The Floor of the Right Atrium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
6.2 Internal Confi guration of the Right Ventricle . . . . . . . . . . . . . . . . . . . . . . . . . 113
6.2.1 The Infl ow and Outfl ow Compartments
of the Right Ventricle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
6.2.2 The Muscular Interventricular Septum, the Conal Septum,
the Membranous Interventricular Septum, the
Septomarginal Trabecula the Supraventricular Crest . . . . . . . . . . . . . . 115
Contents ix
6.2.3 The Right Atrioventricular Junction . . . . . . . . . . . . . . . . . . . . . . . . . . 118
6.2.4 The Pulmonary Valve (the Valve of the Pulmonary Trunk) . . . . . . . . . 124
6.3 The Internal Confi guration of the Left Atrium . . . . . . . . . . . . . . . . . . . . . . . . 128
6.4 The Internal Confi guration of the Left Ventricle . . . . . . . . . . . . . . . . . . . . . . . 131
6.4.1 General Considerations on the Left Ventricle Cavity . . . . . . . . . . . . . 131
6.4.2 The Valvular Apparatus of the Left Atrioverticular Orifi ce . . . . . . . . . 133
6.4.3 The Left Atrioventricular Ring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
6.4.4 The Atrioventricular Cusps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
6.4.5 The Aortic Valve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
7 The Structure of the Heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
7.1 Epicardium and Endocardium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
7.2 Myocardium: Microscopic Infrastructure and Microanatomy . . . . . . . . . . . . . 151
7.2.1 Cardiac Myocyte: General Features
and Microscopic Infrastructure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
7.2.2 Extracellular Matrix: Defi nition, Components, Structure . . . . . . . . . . 154
7.2.3 The Structure of the Myocardium of the Atrium.
The Continuous Atrium Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
7.2.4 Myoendocrine Cardiomyocyte – The Heart as
an Endocrine Organ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
7.2.5 Architecture of the Myocardium- General Considerations.
The Theory of “Shutters” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
7.2.6 The Architecture of the Ventricular Myocardium . . . . . . . . . . . . . . . . 163
7.3 The Fibrous Skeleton of the Heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
7.3.1 General Observations on the Concept of Fibrous Skeleton . . . . . . . . . 179
7.3.2 The Left Fibrous Trigone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
7.3.3 The Right Fibrous Trigone and the Atrioventricular
and Interventricular Membranous Septum . . . . . . . . . . . . . . . . . . . . . . 180
7.3.4 Fila coronaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
7.3.5 The Tendon of Todaro . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
7.3.6 The Tendon of the Conus Arteriosus . . . . . . . . . . . . . . . . . . . . . . . . . . 185
7.4 The Excitoconductive System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
7.4.1 The Sinoatrial Node (Keith-Flack) . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
7.4.2 The Atrioventricular Node . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
7.4.3 The Hiss Bundle, Its Branches
and the Purkinje Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
8 Hearts Vessels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
8.1 Arteries of the heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
8.1.1 General Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
8.1.2 The Left Coronary Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
8.1.3 The Right Coronary Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
8.2 Standardized Myocardial Segmentation and Nomenclature
for Topographic Imaging of the Heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
8.3 The Cardiac Veins: General Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . 224
8.3.1 The Coronay Sinus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
8.3.2 The Tributary Veins of the Coronary Sinus . . . . . . . . . . . . . . . . . . . . . 227
8.3.3 The Veins That Don’t Drain into the Coronary Sinus . . . . . . . . . . . . . 230
8.4 Lymphatics of the Heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232